Bedouin Rural Health Project Improving Access to health care Reconciliation and Health Care Workshop Amman 17-18th December 2008 Fadia Hasna RN, PhD

Bedouin Rural Health Project  Funded by the European Commission  Framework 6 Programme -International Co- operation Programme (INCO-DEV)  With 2-3 Third Member Countries & 2 European or Associated Countries European or Associated Countries  Theme- health system reform

Bedouin Rural Health Project Partners  UK: University of Warwick (lead) University of Oxford University of Oxford  Jordan: The University of Philadelphia  Lebanon: American University of Beirut  France: Cermes, Inserm  Sweden: The University of Stockholm

Bedouin Rural Health Project Aims  Assess current health status, health seeking behaviour and current health service provision (completed) behaviour and current health service provision (completed)  Elicit the views of stakeholders-policy makers, health personnel and Bedouin (completed) health personnel and Bedouin (completed)  Develop model interventions in partnership with stakeholders (in progress)  Evaluate and disseminate the interventions locally, nationally, regionally and internationally locally, nationally, regionally and internationally

Strengths of Health Provision Northern Badia is a priority on political agenda.Northern Badia is a priority on political agenda.  Availability of health insurance Network of health centres at three different levels across a large rural areaNetwork of health centres at three different levels across a large rural area  High coordination amongst MOH, Military and local institutes Availability of MOH databaseAvailability of MOH database

Challenges for Rural Health Provision  Dispersed population, with some mobility  Prevalence Brucella due to livestock raising  The need to balance the individual versus collective rights to health  A young population with reproductive health needs  An aging population with chronic disease.

Typology of Challenges to Access to Health Care for Providers ( Arksey et al, 2004 )  Professional Characteristics  Service Issues  Cultural Competence Issues  Characteristics of the Population  Information & Knowledge Issues

Concerns  Transport and Distance  Quality of care  Emergency care  Childbirth provision  Staff turnover and Gender  Staff Knowledge of Bedouin lifestyle

Expectations of the Rural Population  Unrealistic and high expectations  Uneven understanding of health care system  Focus on specialist care  Lack of regard for general practice or nurses  Use of private doctors

Knowledge and respect for the lifestyle of Bedouin Some of the people from the cities don’t appreciate what a good culture they've got, and how well their culture suits their life style…… I tell westernized Arabs that we have to realize that we are here as their guests. When we go out to visit them we need to respect their culture, and I think that is one of the problems that builds a barrier between some of the city people … The other people in Jordan and westerners don’t appreciate what a great culture they have, and we're not there to change their culture, we're there to help their needs (Policymaker).

Cultural Competence of providers The majority of Bedouins live in the desert. This type of Bedouin is not interested in education, health or drinking water. The Bedouin ’ s sole object is to stay with his herd, buy, sell and trade. He might ask his child to drop out from school and work as a shepherd. It does not matter for him if water is clean or unclean. (Policymaker) “When the Bedouin comes to the centre they stare at him and treat him differently. When the doctor comes to examine him, he won't even touch him. He just looks at him and then he tells him to go. They don't consider him human being although his conditions have made him like this. …They will say this is a Bedouin who's smelly, why do they say that? The Bedouin is a human being. “ (Bedouin man)

Cultural Competence and Communication Skills “I say that if there is something missing in our staff it is the skill of communication. I always stress the importance of communication skills. It is important that when you work in an area you understand the culture. It is important that he speaks the same dialect of the people of the area. It is important to deal with them in the way they like” (Policymaker)

Providers’ Views “Parents have no trust in nursing; they don't trust us at all, even though all we do is First Aid before the doctor comes. They keep asking us what are we doing, what medicine we gave, and what effect it has on the patient” (Nurse). “When some patients come to see a gynaecologist or paediatrician, the nurse comes to take care of the case until the doctor arrives. But people insist that the doctor should see them first. They only want the doctor. In the end they go to a private doctor, then take the medicine and leave”. (Nurse)

Model Intervention 1. Professional training Bedouin Health Module Prepared by Dr. Fadia Hasna Philadelphia University, Faculty of Nursing Dr. Mohammad Al-Smairan Jordan Badia Research and Development Centre

Background  This Bedouin Health module utilizes findings of the data collected in Northern Badia during the years with policy makers, health providers in Northern Badia, and Bedouin men and women  Aim: To sensitize nursing, social work and medical students to the Bedouin culture and health needs in Northern Badia of Jordan making them more aware and culturally sensitive to this local population’s health, economic and psycho-social needs To sensitize nursing, social work and medical students to the Bedouin culture and health needs in Northern Badia of Jordan making them more aware and culturally sensitive to this local population’s health, economic and psycho-social needs

Outline  Structure – 6 class room based sessions combined with a number of field visits Delivered to nursing and social work students 2008  Course Units Unit 1: The Badia Unit 2: Population and socio economic conditions Unit 3: Determinants of Health in the North Badia Unit 4: Health Services Unit 5: Role of women in Health Promotion Unit 6: Possible ways forward

Framework for Evaluation  Pre and Post Test  Focus Groups with nursing and social work students as well as the faculty staff who were involved  This pilot intervention to be transferable to local universities (Al Hashemieh and Al Bayt, Faculties of Nursing)

Other Possible Project Interventions  Recruitment drive of Jordanian Nursing Association in schools in Northeast Badia  Training Bedouin staff – scholarships for Bedouin nurses  Orientation training for staff in clinics in the Northeast Badia  More Health promotion in schools as well as in the clinics on particular issues